Dupilumab Paradoxical AA — SCE Dermatology MCQ

Correct answer: A — Yes — new-onset alopecia areata has been reported during Dupilumab therapy as a paradoxical immune-mediated adverse event

New-onset or worsening alopecia areata during Dupilumab therapy has been reported in case series and is considered a paradoxical immune-mediated adverse event. The proposed mechanism involves Dupilumab shifting the immune balance by blocking Th2 pathways (IL-4/IL-13), potentially upregulating Th1/IFN-gamma pathways that drive the autoimmune attack on hair follicles in AA. This is analogous to paradoxical psoriasis with anti-TNF therapy. Management depends on severity — mild cases may be managed with topical/intralesional corticosteroids while continuing Dupilumab; severe cases may necessitate Dupilumab discontinuation or addition of JAK inhibitor therapy. The association is increasingly recognised in the literature.

Reference: BJD 2021 Dupilumab and AA; JAAD Case Series